Epileptiform electroencephalographic abnormalities in liver transplant recipients

We retrospectively studied patients who had undergone orthotopic liver transplantation and who also had electroencephalography to determine whether epileptiform changes were associated with a poor neurological outcome. Study groups were 36 patients who died after transplantation (141 electroencephalograms) and underwent neuropathological examination, 11 who died (18 electroencephalograms) but did not have autopsy, and a third group of 34 (62 electroencephalograms) who remained alive. Epileptiform activity was seen in electroencephalograms of 14 of the patients who died (11 from the autopsy group) and in 2 of those who remained alive. All had multiple epileptiform abnormalities and clinical or subclinical seizures. The incidence of epileptiform activity after orthotopic liver transplantation was fivefold higher in the nonsurvivors. Serious cerebral structural changes were found in 10 of the 11 patients who underwent autopsy. Epileptiform activity in the electroencephalograms of patients who had undergone orthotopic liver transplantation indicates a poor prognosis. It should alert the clinician to investigate further for potentially treatable causes.     

Neuropathology of heart transplantation

The neuropathology of 18 cardiac transplant recipients was reviewed with the clinical findings. Pathological changes were noted in the central nervous system (CNS) in 94% of the patients, the most frequent being cerebral vascular in origin (72%). Eight patients (44%) had multiple cerebral infarcts and morphologically, a large number of these antedated the transplantation. In addition 4 patients had acute focal ischemic changes which occurred after transplantation. Intracranial hemorrhage was noted in 5 patients (28%), including one case of fatal intracerebral hemorrhage following an acute hypertensive episode after the transplantation. While systemic infection was common (10 patients), there were only 5 cases of intracranial infection; including 3 cases of cytomegalovirus infection, one of candidiasis and one of aspergillosis. Post-transplant seizures, occurring in a third of the patients, were related to a variety of causative factors such as sepsis, intracranial hemorrhage, cerebral ischemia, metabolic encephalopathy and cyclosporin neurotoxicity. Of note in this series was the absence of CNS lymphoma or other systemic lymphoproliferative disorder.     

自体骨髓间充质干细胞培养后经肝动脉介入治疗失代偿期肝硬化1 例

骨髓间充质干细胞在特定环境下可分化成肝干细胞及肝细胞,从而参与肝结构和功能的修复和重构。 目的：进一步验证自体骨髓间充质干细胞培养后经肝动脉介入治疗肝硬化的安全性、可行性及疗效。 方法：1例肝硬化患者进行自体骨髓单个核细胞移植,骨穿采集自体骨髓体外分离纯化骨髓单个核细胞。骨髓单核细胞培养 4 d后经肝动脉插管将其移植入肝脏。移植后4周观察血清白蛋白、胆碱酯酶、凝血酶原活动度、总胆红素、谷丙转氨酶、谷草转氨酶、凝血酶原时间、纤维蛋白原变化情况,观察患者并发症及预后。 结果与结论：培养后骨髓间充质干细胞数量明显增多,患者移植前后各项指标变化情况：移植前血清白蛋白、胆碱酯酶、凝血酶原活动度、谷丙转氨酶、谷草转氨酶、凝血酶原时间、纤维蛋白原分别为29.43 g/L,2 378.5 U /L,47.4%,112.78 U/L,79.36 U/L,17.91 s,2.01 g/L。移植后4周分别为33.30 g/L,2 866.5 U /L,55. 8%,79.01 U/L,56.37 U/L,16.26 s,2.35 g/L。移植后无严重不良事件发生。结果表明,自体骨髓间充质干细胞移培养后植治疗可使失代偿期肝硬化患者肝功能明显改善,治疗安全有效且不良反应小,可作为中晚期肝硬化患者的临床治疗方案。     

肝移植后早期血流动力学的监测

背景：接受肝移植的患者均为晚期肝病患者,由于肝功能损害,心室负荷加重,导致心肌肥大,心肌间质纤维化,心脏收缩、舒张功能同样受到损伤。BioZ.Com无创血流动力学监测仪基于胸腔生物电阻抗,可无损伤地提供反映左心室泵血功能参数及收缩功能参数。 目的：采用美国BioZ.Com无创血流动力学监测仪,检测终末期肝病患者肝移植后早期的血流动力学变化情况。 设计、时间及地点：病例观察,于2005-01/2006-12在解放军总医院第二附属医院干部病房完成。 对象：选择接受原位肝移植的患者50例。 方法：应用美国BioZ.Com 无创血流动力学监测仪监测肝移植患者移植后7 d内血流动力学参数的变化,包括心率、平均动脉压、心输出量、心脏指数、每搏输出量、外周血管阻力、心脏收缩加速指数及胸腔液体量水平等。 主要观察指标：肝移植后早期(ICU内)不同时段患者的血流动力学指标。 结果：肝移植后第2天开始患者心输出量、心脏指数、每搏输出量、心脏收缩加速指数明显低于移植前(P < 0.01),外周血管阻力、胸腔液体量水平明显高于移植前(P < 0.01),这种变化于移植后第3天达到高峰,移植后第7天各项血流动力学指标逐渐恢复至移植前水平。 结论：肝移植后患者血流动力学不稳定,尤以移植后二三天最重。因此,密切监测其血流动力学变化,及时调整治疗方案,是肝移植患者平稳度过围手术期的关键。     

Acute neuropathies after peripheral blood stem cell and bone marrow transplantation

Neuromuscular complications are not uncommon after bone marrow and stem cell transplantation, especially in patients with allogeneic transplantations and graft-versus-host disease. The pathogenesis of these complications remains unclear, but the changes in immune modulation that occur after transplantation are likely to play a key role. We describe 4 patients who developed brachial plexopathy (3 cases) or multiple lumbosacral radiculopathies (1 case) between 5 days and 4 months after autologous peripheral blood stem cell (3 cases) or allogeneic bone marrow transplantation without evidence of graft-versus-host disease (1 case). Infectious, tumor-related, toxic, and metabolic causes were excluded in all cases. Recovery was limited in two cases and nearly complete in the other two patients. Brachial plexopathies and polyradiculopathies are potential complications of peripheral blood stem cell and bone marrow transplantation. It is possible that these disorders may be the result of autoimmune phenomena directed against specific nerve antigens.     

应用荧光原位杂交技术动态监测化疗与干细胞移植后白血病患者的染色体变化

背景：荧光原位杂交技术被广泛应用于白血病异常基因的检测中,但对于应用此项技术比较化疗与移植后疗效的研究尚未见大量报道。 目的：评价荧光原位杂交技术对化疗与移植后白血病患者的监测效果。 方法：新疆医科大学第一附属医院血液二科2009-10/2010-10收治的白血病患者44例,收集标本85份。按照各自采取的主要治疗方案,分为治疗前组,普通化疗组,特殊药物治疗组和造血干细胞移植组。特殊药物治疗组包括全反式维甲酸治疗和甲磺酸伊马替尼治疗患者。 结果与结论：荧光原位杂交技术在诊断与监测白血病微小残留病灶方面较染色体核型分析更为精确;荧光原位杂交结果显示特殊药物治疗组与造血干细胞移植组阳性细胞百分数均明显低于治疗前组和普通化疗组(P < 0.01),但特殊药物治疗组与造血干细胞移植组间差异无显著性意义(P > 0.05);急性移植物抗宿主病发生与移植后1个月荧光原位杂交结果不具有相关性(P > 0.05);移植后1个月、1~6个月、6个月以上荧光原位杂交检测结果差异无显著性意义(P > 0.05)。提示荧光原位杂交技术可以准确而有效的动态检测移植后患者的染色体变化情况,评价患者疾病发展趋势。     

干细胞移植治疗脊髓损伤18例

目的探讨脐带间充质干细胞移植治疗脊髓损伤的疗效。方法对18例脊髓损伤患者给予脐带间充质干细胞6次移植。移植前后按照《美国脊柱损伤协会评估标准》(ASIA评分)及日常生活活动(ADL)量表的Barthel指数给予患者评分,两次评分进行统计学处理。结果有5例患者的《美国脊柱损伤协会评估标准》评分增加,其余13例均无变化,移植前后的评分比较P>0.05。结论脐带间充质干细胞移植治疗脊髓损伤短期内观察疗效不确切。     

肝移植后胰腺炎的诱因分析

背景：肝移植后并发症中急性胰腺炎的发生率相对较低,但移植后重症胰腺炎的致死率确高达50%,加强对移植后并发胰腺炎的预防和治疗,对提高移植存活率具有重要意义。 目的：回顾性分析肝移植后并发胰腺炎的治疗经验。 设计、时间及地点：单中心抽样,回顾性病例分析,于2004-03/2008-03在解放军第二军医大学东方肝胆外科医院完成。 对象：选取解放军第二军医大学东方肝胆外科医院单个医疗组同期内收治的肝移植患者117例,供者均为男性脑死亡志愿捐献者,供受者ABO血型符合。 方法：肝移植患者后常规化验血淀粉酶,根据淀粉酶的最高值及临床表现分为正常组、淀粉酶偏高组(正常上限2倍以内)、单纯高淀粉酶血症组(正常上限2倍以上且无胰腺炎证据)及急性胰腺炎组(有明显临床症状及CT表现)。出现移植后高淀粉酶血症或怀疑胰腺炎的患者均予以抗胰腺炎治疗;对于诊断为急性胰腺炎的患者均予以血管活性物质治疗。 主要观察指标：分析各组患者中各种风险因素的比例,总结移植后胰腺炎的预防及治疗经验。 结果：117例肝移植患者中,移植后淀粉酶增高51例(占43.6%),移植后单纯高淀粉酶血症24例(占20.5%),急性胰腺炎3例(占2.6%,包括1例急性重症胰腺炎)。3例急性胰腺炎患者经抗胰腺炎治疗7~10 d后,其中2例患者症状消失、血淀粉酶下降;1例患者持续腹胀、发热、血象升高,影像检查发现胰腺改变及胰腺周围积液,经2次开腹手术后逐渐痊愈,整个治疗时间40 d。 结论：充分地认识,积极地控制和治疗诱发因素,对降低肝移植后胰腺炎发生率具有重要意义。     

The role of goal cognitions,illness perceptions and treatment beliefs in self-reported adherence after kidney transplantation: A cohort study

Objective

Nonadherence to immunosuppressive medication (IM) after kidney transplantation is related to poorer patient and graft outcomes; therefore research into modifiable factors associated with nonadherence is a priority. In this prospective cohort study we investigated whether changes in goal cognitions, illness perceptions, and treatment beliefs were related to self-reported medication adherence six months after kidney transplantation.

Methods

Interviews were conducted with patients in the out-patient clinic six weeks (T1: n = 113) and six months (T2: n = 106) after transplantation. Self-reported adherence was measured using the Basel Assessment of Adherence to Immunosuppressive Medications Scale (BAASIS© Interview). The Brief Illness Perceptions Questionnaire, Beliefs about Medicines Questionnaire and questions on goal cognitions were also administered at both time points.

Results

Self-reported nonadherence increased significantly between 6 weeks and 6 months after transplantation from 17% to 27%. Importance of medication adherence as a personal goal and self-efficacy to successfully carry out this goal decreased significantly over time. Perceived necessity of immunosuppressive medication was high but significantly decreased over time. Concerns about the medicines were low. There were no significant changes in illness perceptions or concerns over time. An increase in perceived graft longevity (timeline) was related to higher likelihood of nonadherence six months post-transplant. Furthermore, younger adult patients were more likely to be nonadherent six months after transplantation.

Conclusion

The self-reported nonadherence levels found in this study so soon after transplantation demonstrate the need for early and continued intervention after kidney transplantation in order to maximise adherence and consequently clinical outcomes. Changes in (unrealistic) beliefs regarding the longevity of the graft may offer a potential target for intervention among nonadherent patients.     

Amniotic tissue transplantation: clinical and biochemical evaluations for some lysosomal storage diseases.

Amniotic epithelial cells has been used for transplantation in patients with lysosomal storage diseases as an enzyme replacement therapy. But its clinical effect is still the question under debate. We performed amniotic tissue transplantation on patients with different lysosomal storage diseases: one with Tay-Sachs disease, one with juvenile Gaucher disease and one with juvenile metachromatic leukodystrophy. The patient having juvenile Gaucher disease received this grafting twice. Objective clinical improvement was observed in the first trial where this patient showed an increase of soluble beta-glucosidase one week after implantation. No clinical or biochemical changes were seen in the other patients. Although there are some advantages to amniotic tissue transplantation, original methods should be modified to cell transplantation in order to avoid graft-versus-host reaction which could happen in repeated implantation.     

Central pontine myelinolysis after liver transplantation

Eight adults and 3 children out of 85 patients who had neuropathologic examination after death following orthotopic liver transplantation showed central pontine myelinolysis (CPM). Four patients also had extrapontine myelinolysis. Eight patients had significant serum sodium changes. In 5, the fluctuation occurred perioperatively and 4 had a clinical picture consistent with CPM, although no patient had this as an antemortem diagnosis. We emphasize the role of hepatic dysfunction as a cause of CPM and recommend careful monitoring of electrolytes in the perioperative period of patients undergoing liver transplantation.     

自体骨髓间充质干细胞移植治疗终末期肝病39例

目前肝脏移植是治疗终末期肝病的惟一有效手段,但仍存在一些问题,尤其是供体短缺、价格昂贵及免疫排斥反应,自体骨髓间充质干细胞移植可避免以上缺点。 目的：探讨自体骨髓间充质干细胞移植对失代偿期肝硬化和慢性重症患者改善作用。 方法：纳入纳入终末期肝病患者39例,肝炎肝硬化失代偿期患者32例,慢性重肝衰竭患者7例。分离其自体骨髓间充质干细胞,行肝动脉插管自体干细胞移植治疗。移植后1,2,4,8周进行生化检测,并观察其移植后临床症状改善情况及术后不良反应。根据实验室检查结果和临床,分别计算出CTP和终末期肝病模型评分,观察各个时间段分值的变化。 结果与结论：移植后1,2,4,8周,37例(93%)患者丙氨酸转氛酶逐渐降低,白蛋白、胆碱脂酶活力、胆固醇、凝血酶原活动度均升高(P < 0.01)。患者临床症状有明显改善:移植后8周内腹水减轻32例(80%),食欲改善34例(85%),乏力好转37例(93%),腹胀减轻34例(85%)。CTP-B级和CTP-C级评分、终末期肝病模型评分均降低。所有移植患者中未发现严重不良反应及并发症。提示,自体骨髓间充质干细胞移植作为治疗慢性肝衰竭的一种新的安全有效的治疗措施。     

尿趋化因子IP-10和Fractalkine在移植肾急性排斥反应早期诊断中的应用*

背景：相关研究已证实,趋化因子IP-10、Fractalkine在器官移植后急性排斥反应过程中发挥着重要的作用。 目的：检测尿液中IP-10和Fractalkine水平变化,并结合肾组织活检病理,探讨尿液中IP-10 和Fractalkine在移植肾急性排斥反应早期诊断中的意义。 方法：106例同种异体肾移植患者,根据移植后临床表现、实验室检查及肾穿刺组织病理学检查结果,分为急性排斥反应组(n=16)和非急性排斥反应组(n=90);另选择健康志愿者作为正常对照组。用双抗体夹心酶联免疫吸附试验检测尿IP-10和Fractalkine浓度变化。 结果与结论：急性和非急性排斥反应组患者在移植后的尿IP-10及Fractalkine的表达水平均较移植前明显升高,但非急性排斥反应组在移植后7 d呈下降趋势,至第11天降至移植前水平,而急性排斥反应组则持续高表达,IP-10在移植后第1天和Fractalkine在移植后第3天即与急性排斥反应组比较,差异有显著性意义(P < 0.05)。提示,肾移植后尿液中IP-10和Fractalkine水平的检测对于急性排斥反应发生的早期诊断和早期治疗具有重要意义。     

肾移植后他克莫司与五酯胶囊合用致高血钾症1例

背景：肾移植患者由于免疫抑制剂的药物肝毒性,肝功能异常发生率高,对临床出现肝功能异常者,需护肝治疗。但合用护肝药必须监测免疫抑制剂浓度。 目的：探讨肾移植患者他克莫司与五酯胶囊合用对他克莫司浓度及血生化的的影响。 方法：回顾性分析1例以他克莫司为免疫抑制剂的肾移植患者加服及停用五酯胶囊时他克莫司浓度及肾功能、血生化变化。患者因“慢性肾小球肾炎,慢性肾功能不全”于1998-06起行血液透析治疗。2000-08行同种异体尸体肾移植,移植后免服他克莫司+吗替麦考酚酯+泼尼松。移植后4个月患者出现肝功能异常,加用联苯双酯。2010-07-25患者停用联苯双酯,改服五酯胶囊。2010-07-29患者停用五酯胶囊。 结果与结论：服用他克莫司的肾移植受者,合用五酯胶囊,他克莫司血浓度显著升高。由5.3 ng/L升至24.7 ng/L,并合并高血钾症,停用五酯胶囊1周,他克莫司浓度由24.7 ng/L降至6.1 ng/L,血钾由6.4 mmol/L降至4.6 mmol/L。提示移植肾功能稳定的肾移植受者,在加用五酯胶囊,必须严密监测他克莫司血浓度及肝肾功能、电解质,及时调整他克莫司用量,保护移植肾功能。     

儿童肾移植手术12例

分析12例平均年龄(15±1)岁儿童肾移植患儿临床资料,探讨儿童肾移植临床特点及外科移植技巧。移植前静脉输入胶体液维持血压,移植中供肾动脉与髂总动脉作端侧吻合,观察移植后肾功能变化及并发症发生。12例移植过程顺利,移植肾灌注良好,未出现吻合口狭窄、栓塞等并发症,移植肾功能恢复良好。提示肾移植是治疗儿童终末期肾病的较理想手段,严格的配型选择、适宜的移植方式和围移植期处理,恰当的免疫抑制策略和良好的依从性是取得良好效果的关键。     

Psychological functioning and quality of life following bone marrow transplantation: a 3-year follow-up study

OBJECTIVE: To assess changes in quality of life and psychological distress following bone marrow transplantation (BMT) and variables related to this change. METHODS: One hundred twenty-five consecutive patients who underwent bone marrow transplantation (BMT) at the Leiden University Medical Centre between 1987 and 1992 filled in questionnaires measuring quality of life, functional limitations, psychological distress, anxiety, depression, self-esteem, and health locus of control. Measurements were taken before the BMT; 1 month after discharge; and 6 months, 1 year, and 3 years after the BMT. RESULTS: Three years after BMT, a quarter of the patients continued to experience serious functional limitations. Thirteen percent of the patients scored >4 on the General Health Questionnaire (GHQ-12), a percentage comparable to general population prevalence. Quality of life was reported to be good to excellent by almost 90% of the patients at three years. Changes in quality of life could be explained entirely by changes in functional limitations and somatic symptoms. Changes in psychological distress were also related to these measures, and furthermore to baseline psychological functioning. CONCLUSION: Although patients were doing well three years after BMT, there was a group of patients needing help. In interventions special attention should be given to patients with ongoing psychological problems. Emphasis should be on coping with physical limitations.     

肾移植患者围术期麻醉管理：40例资料回顾

背景：从肾移植患者围术期血生化检测结果可以看到,一些酸碱指标及生化指标的变化可能与血液稀释有关。 目的：通过监测肾移植患者围术期血流动力学的变化以及电解质、血生化的改变,麻醉药物使用情况,探讨肾移植患者理想的麻醉管理方法。 方法：分析40例肾移植患者麻醉前、肾动脉血流开放前、血流开放后10 min、手术结束时(T4)各时点平均动脉压、中心静脉压、心率、电解质、血糖和血气参数的变化。 结果与结论：与肾移植患者麻醉前比较,血流开放后10 min平均动脉压、中心静脉压、pH、HCO3-、BE显著降低(P < 0.01),K+和葡萄糖明显增加(P < 0.01)。与肾动脉血流开放前比较,血流开放后10 min平均动脉压、葡萄糖、pH、HCO3-、BE明显降低而心率明显增高(P < 0.05)。说明充分的移植前准备,合理的麻醉药物选择,以及围术期的循环、呼吸及水电解质酸碱平衡的维持是肾移植术全身麻醉成功的关键。     

同种异体犬单肺移植过程中的凝血功能

背景：体外循环条件下,肺移植围手术期有凝血和纤溶系统的激活,而对非体外循环下肺移植围手术期凝血功能变化研究较少。 目的：检测受体犬单肺移植过程中凝血功能的变化。 方法：将健康杂种雄性犬以随机抽签法分成供体和受体两组,行单肺移植,分别于麻醉诱导后20 min,再灌注前10 min,再灌注后10 min,再灌注后60 min,采用Sonoclot凝血仪检测受体犬全血激活凝集时间、凝集速率、血小板功能。 结果与结论：再灌注后10 min全血激活凝集时间数值较麻醉诱导后20 min,再灌注前10 min,再灌注后60 min明显延长(P < 0.001)。凝集速率和血小板功能各组之间差异均无显著性意义。说明犬肺移植过程中全血激活凝集时间在再灌注后10 min明显延长,再灌注后1 h 回到正常水平,凝集速率和血小板功能在各个时点变化不大。     

Normalization of T2 signal abnormalities in hemispheric white matter with liver transplant

OBJECTIVE: To determine whether edema can be assessed by MRI using T2-weighted signal intensity of hemispheric white matter in cirrhotic patients. METHODS: Fast-FLAIR and magnetization transfer images were obtained before (24) and after (11) liver transplantation. T2-weighted abnormalities on baseline scans and their time-course changes were analyzed and compared with MT ratios (MTR). RESULTS: Fast-FLAIR baseline images showed faint to substantial, bilateral, symmetric increased signal intensity along the hemispheric white matter in or around the corticospinal tract in 23/24 patients. After liver transplantation the signal abnormalities gradually recovered. This gradual decrease in signal intensity correlated with an increase in MTR values. CONCLUSION: Asymptomatic symmetric high-signal intensity in the hemispheric white matter on fast-FLAIR MR images is present in cirrhosis. Normalization of this finding after successful liver transplantation and its correlation with MTR values suggest that this signal abnormality reflects mild edema.     

肝移植相关心理问题分析

肝移植是治愈终末期肝病的有效方法,但由于移植本身的特殊性及经济状况等原因,移植给患者带来了巨大的心理压力。文章分析了肝移植患者移植前及移植后存在的心理问题,证实了移植前患者除了有躯体不适外,还存在由原发病所致的不同程度的精神社会功能缺损及生活质量水平下降导致的心理障碍;移植后主要为忧郁、过分乐观、放纵的心理。探讨了缓解肝移植相关问题的思路和对策,得出结论：对患者进行心理疏导,满足患者需求心理,帮助患者了解肝移植知识有助于减轻患者心理压力,使患者积极配合医疗并接受移植。